Provider Demographics
NPI:1811659808
Name:GAMBEL, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:GAMBEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 OAKWATER DRIVE
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503
Mailing Address - Country:US
Mailing Address - Phone:337-781-7634
Mailing Address - Fax:
Practice Address - Street 1:717 CURTIS DRIVE SUITE A
Practice Address - Street 2:
Practice Address - City:RAYNE
Practice Address - State:LA
Practice Address - Zip Code:70578
Practice Address - Country:US
Practice Address - Phone:337-334-7554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-07
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP221983208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty